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Drawing on the Legacy of General Practice to Build the Future of Family Medicine

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Drawing on the Legacy of General Practice to Build the Future of Family Medicine Vol. 36, No. 9 631 Special Article Drawing on the Legacy of General Practice to Build the Future of Family Medicine John P. Geyman, MD “The farther backward you look, the farther forward concern became sharply focused on the deficit of gen- you can see.”—Winston Churchill eralist physicians.4 As family medicine now undergoes its own self-assessment, it is therefore worthwhile to Much has been accomplished by family medicine revisit its generalist roots. This paper has four objec- since its advent as a specialty in American medicine 35 tives: (1) to identify four streams from the literature of years ago in 1969. The steady decline in general prac- the legacy of general medical practice, (2) to briefly tice has been arrested and its ranks replaced by gradu- assess some major trends as they relate to our general- ates of family medicine residencies. Family medicine ist legacy, (3) to describe the current chaos in primary has gained a foothold in most of the nation’s medical care, and (4) to compare two alternative scenarios for schools, and family physicians still account for a larger the future of family medicine, primary care, and the proportion of office visits to US physicians than any health care system itself. other specialty. Despite such progress, however, the country’s health Streams in the Legacy of General Practice care (non) system has undergone a major transforma- Today’s tension between the generalist and the spe- tion to a market-based system largely dominated by cialist has a long history dating back more than 4,000 corporate interests and a business ethic. The goal envi- years. In the Nile Valley of Egypt before 2,000 BC, sioned in the 1960s of rebuilding the US health care Herodotus noted that “The art of medicine is thus di- system on a generalist base, with all Americans having vided: each physician applies himself to one disease ready access to comprehensive health care through a only and not more.”5 At no time over the centuries, personal physician, has not been achieved. Primary care however, has the generalist disappeared from the land- has become splintered into many competing interests, scape of medical practice, though generalist practice and public policy concerning health care reform is con- has been forced to reinvent itself on many occasions as fused. Clouds now obscure the horizon as all of the a phoenix rising from the ashes.4 Despite variations from primary care specialties look to their future, and each one period of history to another, four streams sort out is actively involved in internal reassessment and strate- in the ongoing legacy of general medical practice. gic planning. In their insightful analysis of current threats to generalism and primary care itself, Sandy and Broad Scope of Clinical Skills and Orientation Schroeder even pose the question whether primary care Although clinical knowledge and skills change mark- in this new era is in a state of disillusion or dissolu- edly from one time to another as the science and tech- tion.1 In family medicine, internal reassessment has nology of medicine advance, the generalist invariably been well described in the Keystone III papers,2 as well retains an orientation to apply a broad range of clinical as the recently released report of the Future of Family skills to the majority of illnesses presented by patients Medicine Project.3 to his or her care. As Gayle Stephens, MD, has ob- Family medicine did not arise de novo in 1969. It served: was preceded by a longstanding tradition of generalism in medical practice. From those roots, family medicine The sine qua non is the knowledge and skill that al- was born as a specialty in its own right when public lows a physician to confront relatively large numbers of unselected patients with unselected conditions and Fam Med 2004;36(9):631-8.) to carry on therapeutic relationships with patients.6 The natural climate favoring the emergence of fam- From the Department of Family Medicine (Professor Emeritus), University ily medicine from general practice was well stated by of Washington. Ian McWhinney, MD, in the 1970s in these words:7 632 October 2004 Family Medicine It is no accident that family medicine is emerging at a acted as general practitioners, with their medical roles time when the interrelatedness of all things is being and training requirements firmly established by law.10 rediscovered, when the importance of ecology is being forced on one’s awareness—when scientists, especially The Healer those in the life sciences, are beginning to react to the As Hiram Curry, MD, observed in his classic article scientific bias against integration, synthesis, and tele- on the phoenix, the mythical bird of ancient Egypt that ology—when human values are being asserted over arises generation after generation from its own ashes, technology and when the importance of enduring and every society for thousands of years has had its own stable human relations is being discovered anew. version of a medicine man or healer living in its midst. Examples include the shaman of primitive tribes, the Being There With a Community Perspective scholar-physician of ancient Greece, the granny woman As part of the community, generalist physicians need of the American frontier, and the general practitioner to have a community perspective to prevent, recognize, in 20th century Western society.4 Lewis Barnett, MD, or manage illness presented by patients in their prac- reflecting on his experience as a rural family physician tice. These characteristics of family medicine, as elu- in more recent years, carries the healer tradition for- cidated by McWhinney, bring this point home (Table ward with this observation:11 1).8 Many illnesses cannot be effectively managed with- In each of us, there probably is a touch of the artist. out dealing with their larger sociologic, cultural, and The medium through which we work is the human body, economic realities. The work of Jack Geiger, MD, and mind, and spirit. The personal touch remains the key to the Broad Street pump provides an excellent illustra- unlocking the secrets of the moment. tion of this point.9 The bond between commitment to community and Edmund Pellegrino, MD, views today’s trends as rais- the social contract to provide medical care is well ex- ing three basic options for the future role of the physi- emplified by the experience of the apothecaries in cian vis-à-vis the patient: (1) the physician as scientist, England more than 400 years ago. Originally general with the ethical imperative being competence (ie, a shopkeepers in the early 1600s, apothecaries earned craftsman’s ethic, the predominant one today), (2) the public acceptance to treat the sick during the plague of physician as businessman, with medical care a com- 1665, when many physicians left the community, to- modity transaction reduced to contract or business eth- gether with their more affluent patients, to less risky ics, and (3) the physician as healer, involving a cov- locales in the countryside. Despite strong opposition enant with and concern for the patient as a human be- from the Royal College of Physicians of London in later ing; concern for illness, not just disease; and ethics years, apothecaries extended their roles of compound- based on obligation to the patient’s needs. Based on its ing over-the-counter prescriptions to prescribing for and commitment to care for the human person both scien- treating patients at home. From the mid-1800s on they tifically and with compassion, Pellegrino suggests that family medicine can only choose the covenantal model.12 Table 1 Research Despite a widespread misperception to the contrary, Characteristics of Family Medicine, there is a long history of important research in the legacy Elucidated by Ian McWhinney, MD of general practice, especially in its earlier years. These examples make the point. 1. The pattern of illness approximates to the pattern of illness in the community, ie, there is: • James MacKenzie, MD’s systematic observations a. A high incidence of transient illness of his patients over 20 years in the late 1800s as a gen- b. A high prevalence of chronic illness eral practitioner in Burnley, a cotton manufacturing c. A high incidence of emotional illness town in Lancashire, Scotland, laid the foundation for 2. The illness is undifferentiated, ie, it has not been previously assessed by modern cardiology. As a result of close observation and any other physician. careful record-keeping, he was able to classify presys- 3. Illnesses are frequently a complex mixture of physical, emotional, and tolic murmurs by prognosis, determine the prognosis social elements. of extra systoles, and elucidate dyspnea as a symptom of heart failure. As part of his continuous studies, he 4. Disease is seen early, before the full clinical picture has developed. invented the polygraph. He later conducted a world- 5. Relationship with patients is continuous and transcends individual famous cardiology practice in London, and upon re- episodes of illness. tirement returned to St Andrews, Scotland, to establish a medical research institute for the study of the natural history of disease.13,14 Special Article Vol. 36, No. 9 633 • William Pickles, MD, as a general practitioner and mostly within internal medicine, and is projected to health officer in the Aysgarth Rural District in England more than triple in size in coming years to the approxi- during the early 1900s, carried out continuous epide- mate size of the specialty of cardiology.22 A counter- miologic studies of infectious diseases in the rural com- trend in some family medicine teaching centers has been munities of his district. His work determined the incu- to develop 1-year fellowship programs, with an em- bation periods of several infectious diseases, including phasis on more advanced obstetrical and procedural measles and varicella.15 skills needed in rural practice, but these are few in num- • Jack Medalie, MD, as a general practitioner in Is- ber and have not influenced the overall decrease in rael, studied angina pectoris in 10,000 men, demon- scope of practice within family medicine.
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